Finding into death of Baby Jacob Hill
Deceased
Jacob Hill
Demographics
0y, male
Coroner
Coroner Jacqui Hawkins
Date of death
2008-02-10
Finding date
2014-02-24
Cause of death
complications of intrauterine hypoxia
AI-generated summary
Baby Jacob Hill died from intrauterine hypoxia following an obstructed labour managed at Sunshine Hospital. A 39-week primiparous labour was complicated by deep transverse arrest. After initial assessment suggesting caesarean delivery, the consultant (Dr D.) elected to trial forceps delivery, which failed due to cephalopelvic disproportion. Emergency caesarean followed, but Baby Jacob was born severely hypoxic (Apgar 2 at 1 min, 0 at 5 min) and died despite resuscitation. Key preventability factors included poor communication between junior registrars and senior consultant, incomplete handover of management plans, delayed review of labour progress, and inadequate documentation. While individual clinical decisions were appropriate in context, systemic failures in communication and escalation contributed to the cascade of events. Post-mortem identified placental chorioamnionitis indicating antenatal infection.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- deep transverse arrest position
- cephalopelvic disproportion
- failed trial of forceps delivery
- placental chorioamnionitis (post-mortem diagnosis)
- inadequate communication at handover between registrars
- unclear labour management plan not documented
- delayed review of labour progress by registrar
- prolonged labour with foetal hypoxia
- delay in caesarean section due to anaesthetic difficulties
Coroner's recommendations
- Obstetricians are to ensure obstetric registrars undertake vaginal examinations following labour augmentation to assess progress
- Obstetric registrars are to be advised at orientation they must contact the consultant obstetrician on all labouring women at handover times each day
- Escalation in communication to consultant obstetrician is to be included in midwife orientation so it is clear they can call consultants directly
- Any anticipated delay in commencing augmentation of labour is to be communicated to the responsible consultant by the patient's midwife
- Anaesthetic registrars are to have more formal neonatal resuscitation education
- Improvement in communication with the paediatric consultant is to be achieved using a mobile phone held by the paediatric registrar to bypass switchboard for direct contact for all emergency situations
- Improved neonatal resuscitation programs by having a neonatologist attend Western Health from a tertiary neonatal unit for registrar and midwife education
Full text
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